By Annie Sparrow, Icahn School of Medicine at Mount Sinai
New York Times columnist Nick Kristof recently nominated Syria as the world capital of human suffering.
He has a point. It’s not just the bombs, bullets, and now gas rained down upon the civilian population. The Assad regime is also targeting the people, facilities and services that used to provide health care to the citizens of Syria, and which if restored, could even now considerably reduce that suffering.
War is obviously horrible for your health. Collateral damage (the unintentional “side effects” of conflict on civilians when war is conducted according to the rules) is bad enough, but how do you capture what happens when civilians are the object of attack, hospitals are intentionally destroyed, breadlines are deliberately bombed, doctors are targeted for detention and torture, schools are set on fire, and public health systems are shut down?
Last month, I went to Lebanon to launch a population-level study of the long-term impact of the abuses in Syria on civilian health; in other words, to measure some of this suffering, to demonstrate not just the direct effects on health at the moment of an abuse, but the longitudinal effects of sustained denial of medical care. I talked with the haves and the have-nots, the registered and the unregistered, Syrians and Palestinians, Christians and Muslims, fighters, rebels and civilians of all kinds.
Violations of medical neutrality
They told me about violations of medical neutrality at every level – naming the hospitals, clinics and pharmacies destroyed, the clearly marked ambulances gunned down, the paramedics shot, the pharmacists and doctors tortured to death. And they told me about the impact on themselves and their families.
I saw children with asthma and allergies without their inhalers or epipens. A 10-year-old with cerebral palsy without his wheelchair or glasses, left behind in Raqqa when the shelling started and his mother had to pick him up and run for their lives. People living with tuberous sclerosis and schizophrenia, heart disease and hypertension without access to either medication or the specialists that used to look after them. Mothers who “miscarried” at five, six or seven months after missile attacks; others whose babies were premature or stillborn. I played with smiling babies too – but also those with pertussis and pneumonia, malnourished infants with giardia and rickets, unvaccinated and unprotected.
The widespread evidence of physical trauma is particularly striking: the injuries and amputations, the disabilities and disfigurements, hemiplegias and handicaps. I saw adults and children with paralysed, useless hands, no longer able to write their name. Harmed and humiliated men who had lost not just a limb but also their livelihood, their ability to provide and protect their families.
Field hospitals more like a field
The “field hospitals” that are often the only medical option in rebel-held territory are more like a field than a hospital. A tent between farms, a room in a basement, staffed not by orthopaedic, plastic and neurosurgeons but by internists and nurses who can only stem the hemorrhage, stitch up the wounds and save the life of those injured, whether the patient is a 10-year-old girl with a severed arm from a missile during Eid, a rebel fighter or a relief worker.
There is no option or surgical expertise for more complex nerve reattachment, muscle repair or tendon transfer, let alone fixation of fractures or reconstructive surgery.
A spinal injury doesn’t have to lead to hemiplegia, a head injury shouldn’t have to result in loss of vision, yet imaging to see where the shrapnel is lodged, let alone the surgical capacity to restore function is pretty much available only for those who are allowed to enter government-controlled hospitals.
No pain medication is awful, no antibiotics means war wounds become infected easily, leading to sepsis and gangrene.
The Syrian military also target the field hospitals. For many sick and injured I interviewed, it was too dangerous even to attempt to reach these clinics. One mother has a 15-year-old in Damascus who lost half his face to a shell, but he is unable to travel to Beirut for medical care because vans carrying the injured to Lebanon are targeted too. Another man witnessed 22 friends, all travelling to Beirut for the surgeries they needed that were unavailable in Syria. all killed when the medical transport was targeted by a missile.
A return to the 19th century
Beyond physical injuries, I was struck by the rise of infectious diseases that are more reminiscent of 19th-century Britain. In both places, the rapid urbanisation, overcrowded living conditions, lack of sanitation and waste disposal, the use of child labour and food insecurity led to a radical increase in infectious disease and infant mortality.
And yet in Syria we are seeing not only the usual suspects of typhoid and dysentery, but also leishmaniasis, an exceptionally nasty skin disease which, left untreated, leads to permanent facial scarring. Before the war there were fewer than 3,000 cases in Syria, and there were some 250 treatment centres across the country. Now, as the sandflies responsible for spreading this condition breed out of control, as the trash piles up and sewage lines the streets, and with the treatment centres long shut down, there are estimated to be more than 100,000 cases, and counting.
Syria used to have free public hospitals and manufactured all its own medications. There were all kinds of specialists and allied health services, and medications were cheap. Before the war, virtually everyone had running water and rubbish collection. Now, no vaccination means outbreaks of measles, and no pharmacies mean people dying of hypertension and heart disease. No contraception and no maternal health care lead to unplanned pregnancies at a time when antenatal and maternal health is denied. Without specialist surgeons, lacerations become loss of function, wounds become amputations.
If we can’t stop the killing in Syria, let’s at least pry open the borders so that aid and medical care will flow freely into Syria, instead of refugees flowing out, and we might at least curtail the spiralling of Syria from a middle-income country into one with diseases of poverty. And as the world mobilises to stop the Syrian military’s use of chemical weapons, let us also mobilise to stop its use of another weapon of mass destruction: the deliberate attacks on medical care.
This is an edited version of an article that was originally published on Syria Deeply.
Annie Sparrow does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.